appointment timetables is an elusive art, especially on those days when dental “toothaches” have been shoehorned into already busy books. Logic dictates that many such emergency patients tend to be poor attenders. Tey are oſten anxious and delay treatment until the situation is dire. Commencing an unscheduled discussion


of the risks and benefits of endodontics versus surgical extraction (as well as non-intervention) in the middle of a busy session can be daunting and may trigger a panic attack (usually by the patient but sometimes by the dental nurse). Here the temptation to hand out a prescription


antibiotic treatment is a necessity futile


without further (time-consuming and probably fraught) consideration of curative treatments may be irresistible. Te patient may be delighted at the time,


but the relief provided by antibiotics is likely to be, at best, temporary. Te recurrent symptoms are oſten – in the patient’s mind, at least – more severe and usually coincide with a wedding, job interview or Caribbean cruise. Paradoxically, the resulting complaint tends to focus on why antibiotics were prescribed. A gentle reminder that, on the day in question, time was at a premium is unlikely to garner much sympathy and, if the patient makes a claim, may be seized upon by solicitors as an indefensible consenting failure. Montgomery acknowledges that there


will be practitioners “…who are more hurried…” but maintains that these practitioners are “…obliged to pause and engage in the discussion which the law requires”. It is anticipated that this “… may not be welcomed by some healthcare providers…” No kidding. In the absence of systemic involvement,


for example, reliance on antibiotics may be very hard to justify. As this message is recognised and accepted by the dental profession, we might expect the numbers of prescriptions to fall which, in turn, makes a contribution to the battle against the tide of antibiotic-resistant bugs.


Exception to the rule Tere is, however, one small development which may buck this trend. Up until July 2016, NICE Guideline 64 included the unequivocal recommendation that antimicrobial prophylaxis against endocarditis should not be employed for patients undergoing dental treatment. Tis engendered significant disquiet, especially amongst at-risk patients who, prior to 2008 (when these NICE guidelines were first published) had always been advised to take prophylactic antibiotics prior to procedures such as scalings and extractions. Certainly, the patients’ oſt-expressed


desire to take the standard dose of amoxicillin (assuming they weren’t allergic) was as profound as it was understandable. However, there were no exceptions to the NICE recommendations and the doctrine that patients cannot require treatments contrary to a clinician’s best judgement (invariably informed by authoritative bodies such as NICE) prevailed. Yet this remained a controversial issue,


WINTER 2016


with commentators pointing to the disparity between the position set out by NICE and the contrary views of, for example, the European Society for Cardiology. A degree of consensus was finally reached following the insertion (rather surreptitiously) of one word into the NICE guideline, which now states that “antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures” (my emphasis). It may be that this amendment was, to


some extent, a consequence of the Montgomery ruling which provides that patients must be made “…aware of any material risks involved in any recommended treatment…” Te “… test of materiality is whether, in the circumstances of the particular case, a reasonable person in the patient’s position would be likely to attach significance to the risk…” Recognised bodies of clinical opinion


(other than NICE) have been suggesting for some time that, for example, a dental extraction without prophylaxis for a high-risk patient may cause a recurrence of endocarditis. Tis is a particularly serious condition and it is likely that a high-risk patient would attach significance to that risk. Terefore, it may have been that Montgomery would have justified or even compelled the introduction of prophylaxis into the consenting discussion, even if NICE had not been revised.


In conclusion… Tere will undoubtedly be occasions in which the provision of antibiotics is clinically indicated. It is also possible that digression from prescribing guidelines could be justified by a coherent, scrupulously recorded diagnostic and consenting process. However, this is a hot-button issue which attracts plenty of publicity. It is therefore unsurprising that third parties, especially the GDC, will cross-reference the dentist’s antibiotic use and regimens with authoritative guidelines when considering complaints and reviewing records. Patient expectations, complex diagnoses


and time-limitations conspire to exert significant pressure on the beleaguered practitioner. However, the time-honoured tradition of reaching for the prescription pad when in a tight spot has had its day.


n Doug Hamilton is a dental adviser at MDDUS


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